Disseminated strongyloidiasis: Breaking brain barriers

Abstract

Strongyloides stercoralis (SS) is one of the most overlooked helminthic infections despite being highly endemic in tropical and subtropical areas. In immunocompromised patients, especially those on long-term steroids, infection can often escalate to fatal dissemination into major organs. We present a compendium of two immunocompromised patients, who were on high-dose steroids and presented with worsening neurological status. Cerebrospinal fluid analysis was notable for larvae of SS as diagnosed by direct visualization. A syndrome of SS hyperinfection with dissemination was made after stool, and sputum samples also revealed SS larvae. SS is an elusive disease and should be considered early on, especially in endemic regions like India. Early diagnosis and prompt initiation of antihelminthic therapy is indispensable for favorable outcomes.

Strongyloides stercoralis Dissemination and Hyperinfection Associated with Long-Term Steroid Treatment in a Neurosurgical Population

“…Disseminated strongyloidiasis afecting the brain and meninges is rare, but some cases have been described in the literature sometimes only with postmortem diagnosis; in some cases, central nervous system (CNS) invasion is documented antemortem by isolation of S. stercoralis larvae in CSF or brain [14][15][16][17][18][19]. In our frst case, even though no distinct larval forms were observed in CSF samples, CNS involvement was presumed due to PCR detection of S. stercoralis nucleic acids in the patient's CSF and unexplained prolonged encephalopathy.…”

Latent Strongyloides stercoralis in an Asymptomatic Male With Chronic Peripheral Eosinophilia

“…This testing, although seemingly necessary at the time, could have been avoided by evaluating the most likely risk factors based on his demographic information. Sebastian et al also found that the lifetime prevalence of parasitic infections in southern India could be as high as 97% [ 9 ]. Therefore, the patient could have avoided excessive testing and a reduced risk of overtreatment [ 11 ].…”

“…A closer evaluation of the patient’s demographic profile and his immigration status from India meant that there was a possibility of a clinically latent parasitic infection. Sebastian et al found that among asymptomatic individuals in various parts of southern and northern India, the prevalence of Strongyloides ranged from 20% to higher than 90% [ 9 ]. The decision was then made to test for parasitic infections, and Strongyloides O&P (ova and parasite), as well as anti-Strongyloides IgG, were both positive.…”

“…One other important consideration is that patients with latent infections can have a potentially overwhelming resurgence of the parasite in cases where they may be immunocompromised, such as in high-dose corticosteroid therapy [ 8 ]. In these cases, the dissemination of parasitic infections in the context of immunomodulatory drugs has been linked to high rates of mortality [ 9 ]. Hence, in patients who may have suspected latent parasitic infections, care should be taken prior to initiation of high-dose corticosteroids [ 10 ].…”